PRISM-E: comparison of integrated care and enhanced specialty referral in managing at-risk alcohol use

Interventions targeting patients with co-occuring severe mental illness and substance use (dual diagnosis) in general practice settings - a scoping review of the literature

BACKGROUND

People with dual diagnosis die prematurely compared to the general population, and general practice might serve as a setting in the healthcare system to mend this gap in health inequity. However, little is known about which interventions that have been tested in this setting.

AIM

To scope the literature on interventions targeting patients with dual diagnosis in a general practice setting, the outcomes used, and the findings.

DESIGN AND SETTING

A scoping review of patients with dual diagnosis in general practice.

METHODS

From a predeveloped search string, we used PubMed (Medline), PsychInfo, and Embase to identify scientific articles on interventions. Studies were excluded if they did not evaluate an intervention, if patients were under 18 years of age, and if not published in English. Duplicates were removed and all articles were initially screened by title and abstract and subsequent fulltext were read by two authors. Conflicts were discussed within the author group. A summative synthesis of the findings was performed to present the results.

RESULTS

Seven articles were included in the analysis. Most studies investigated integrated care models between behavioural treatment and primary care, and a single study investigated the delivery of Cognitive Behavioral treatment (CBT). Outcomes were changes in mental illness scores and substance or alcohol use, treatment utilization, and implementation of the intervention in question. No studies revealed significant outcomes for patients with dual diagnosis.

CONCLUSION

Few intervention studies targeting patients with dual diagnosis exist in general practice. This calls for further investigation of the possibilities of implementing interventions targeting this patient group in general practice.

Providing Behavioral Health Care in PACE - A Review of Federal and State Manual Regulations

OBJECTIVES

Present analysis of the federal and state regulations that guide The Program of All-Inclusive Care for the Elderly (PACE) operations and core clinical features for direction on behavioral health (BH).

DESIGN

Review and synthesize the federal (Centers for Medicare and Medicaid Services [CMS]) and all publicly available state manuals according to the BH-Serious Illness Care (SIC) model domains.

SETTING AND PARTICIPANTS

The 155 PACE organizations operating in 32 states and the District of Columbia.

METHODS

A multipronged search was conducted to identify official state and federal manuals guiding the implementation and functions of PACE organizations. The CMS PACE website was used to identify the federal PACE manual. State-level manuals for 32 states with PACE programs were identified through several sources, including official PACE websites, contacts through official websites, the National PACE Association (NPA), and public and academic search engines. The manuals were searched according to the BH-SIC model domains that pertain to integrating BH care with complex care individuals.

RESULTS

According to the CMS Manual, the interdisciplinary team is responsible for holistic care of PACE enrollees, but a BH specialist is not a required member. The CMS Manual includes information on BH clinical functions, BH workforce, and structures for outcome measurement, quality, and accountability. Eight of 32 PACE-participating states offer publicly available state PACE manuals; of which 3 offer information on BH clinical functions.

CONCLUSIONS AND IMPLICATIONS

Regarding BH, federal and state manual regulations establish limited guidance for comprehensive care service delivery at PACE organizations. The absence of clear directives weakens BH care delivery due to a limiting the ability to develop quality measures and accountability structures. This hinders incentivization and accountability to truly all-inclusive care. Clearer guidelines and regulatory parameters regarding BH care at federal and state levels may enable more PACE organizations to meet rising BH demands of aging communities.

Integration of pharmacotherapy for alcohol use disorder treatment in primary care settings: A scoping review

BACKGROUND

Alcohol use disorder (AUD) represents the most prevalent addiction in the United States. Integration of AUD treatment in primary care settings would expand care access. The objective of this scoping review is to examine models of AUD treatment in primary care that include pharmacotherapy (acamprosate, disulfiram, naltrexone).

METHODS

The team undertook a search across MEDLINE, PsycINFO, CINAHL, the Cochrane Central Register of Controlled Trials, and Web of Science on May 21, 2021. Eligibility criteria included: patient population ≥ 18 years old, primary care-based setting, US-based study, presence of an intervention to promote AUD treatment, and prescription of FDA-approved AUD pharmacotherapy. Study design was limited to controlled trials and observational studies. We assessed study bias using a modified Oxford Centre for Evidence-based Medicine Rating Framework quality rating scheme.

RESULTS

The qualitative synthesis included forty-seven papers, representing 25 primary studies. Primary study sample sizes ranged from 24 to 830,825 participants and many (44 %) were randomized controlled trials. Most studies (80 %) included a nonpharmacologic intervention for AUD: 56 % with brief intervention, 40 % with motivational interviewing, and 12 % with motivational enhancement therapy. A plurality of studies (48 %) included mixed pharmacologic interventions, with administration of any combination of naltrexone, acamprosate, and/or disulfiram. Of the 47 total studies included, 68 % assessed care initiation and engagement. Fewer studies (15 %) explored practices surrounding screening for or diagnosing AUD. Outcome measures included receipt of pharmacotherapy and alcohol consumption, which about half of studies included (53 % and 51 %, respectively). Many of these outcomes showed significant findings in favor of integrated care models for AUD.

CONCLUSIONS

The integration of AUD pharmacotherapy in primary care settings may be associated with improved process and outcome measures of care. Future research should seek to understand the varied experiences across care integration models.

Neurocognitive and substance use disorders in older adults: challenges and evidence

Purpose

This study aims to review the presentation of substance use disorders in older adults, how addiction intertwines with neurocognitive disorders and how to approach this vulnerable population.

Design/methodology/approach

Electronic data searches of PubMed, Medline and the Cochrane Library (years 2000–2021) were performed using the keywords “neurocognitive,” “dementia,” “substance use,” “addiction,” “older adults” and “elderly.” The authors, in consensus, selected pivotal studies and conducted a narrative synthesis of the findings.

Findings

Research about substance use disorders in older adults is limited, especially in those with superimposed neurocognitive disorders. Having dual diagnoses can make the identification and treatment of either condition challenging. Management should use a holistic multidisciplinary approach that involves medical professionals and caregivers.

Originality/value

This review highlights some of the intertwining aspects between substance use disorders and neurocognitive disorders in older adults. It provides a comprehensive summary of the available evidence on treatment in this population.

Práticas de Atenção Primária à Saúde na área de drogas: revisão integrativa

RESUMO O objetivo deste estudo foi o de identificar e analisar as práticas voltadas ao consumo prejudicial de drogas na Atenção Primária à Saúde. Trata-se de Revisão integrativa que buscou estudos nas fontes Medline e Lilacs utilizando os termos ‘Atenção Primária à Saúde’ e ‘Redução do Dano’. Como resultado, incluiram-se 52 estudos, analisados de acordo com os arcabouços teóricos que orientam as práticas em saúde. Tais estudos foram sintetizados em três categorias empíricas: comportamento de risco, que incluiu intervenção breve, programas para prevenir e diminuir o uso de drogas, entre outros; fatores determinantes, que incluiu visitas domiciliares, práticas grupais e organizacionais; e necessidades em saúde, que incluiu práticas educativas emancipatórias. Conclui-se que, majoritariamente, os estudos abordam o uso de drogas pela categoria risco, com proposição de práticas para adaptação social. As intervenções relativas aos determinantes promovem a saúde, propondo melhorias em ambientes de vida e trabalho. Práticas críticas às relações sociais estabelecidas pelo complexo das drogas são minoritárias e envolvem complexidade operacional.

Addressing Common Challenges in the Implementation of Collaborative Care for Mental Health: The Penn Integrated Care Program

PURPOSE

We developed and implemented a new model of collaborative care that includes a triage and referral management system. We present initial implementation metrics using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

METHODS

Primary care clinicians in 8 practices referred patients with any unmet mental health needs to the Penn Integrated Care program. Assessments were conducted using validated measures. Patients were primarily triaged to collaborative care (26%) or specialty mental health care with active referral management (70%). We conducted 50 qualitative interviews to understand the implementation process and inform program refinement. Our primary outcomes were reach and implementation metrics, including referral and encounter rates derived from the electronic health record.

RESULTS

In 12 months, 6,124 unique patients were referred. Assessed patients reported symptoms consistent with a range of conditions from mild to moderate depression and anxiety to serious mental illnesses including psychosis and acute suicidal ideation. Among patients enrolled in collaborative care, treatment entailed a mean of 7.2 (SD 5.1) encounters over 78.1 (SD 51.3) days. Remission of symptoms was achieved by 32.6% of patients with depression and 39.5% of patients with anxiety. Stakeholders viewed the program favorably and had concrete suggestions to ensure sustainability.

CONCLUSIONS

The Penn Integrated Care program demonstrated broad reach. Implementation was consistent with collaborative care as delivered in seminal studies of the model. Our results provide insight into a model for launching and implementing collaborative care to meet the needs of a diverse group of patients with the full range of mental health conditions seen in primary care.

The primary care assessment and research of a telephone intervention for neuropsychiatric conditions with education and resources study: Design, rationale, and sample of the PARTNERs randomized controlled trial

While most patients with depression, anxiety, or at-risk drinking receive care exclusively in primary care settings, primary care providers experience challenges in diagnosing and treating these common problems. Over the past two decades, the collaborative care model has addressed these challenges. However, this model has been adopted very slowly due to the high costs of care managers; inability to sustain their role in small practices; and the perceived lack of relevance of interventions focused on a specific psychiatric diagnosis. Thus, we designed an innovative randomized clinical trial (RCT), the Primary Care Assessment and Research of a Telephone Intervention for Neuropsychiatric Conditions with Education and Resources study (PARTNERs). This RCT compared the outcomes of enhanced usual care and a novel model of collaborative care in primary care patients with depressive disorders, generalized anxiety, social phobia, panic disorder, at-risk drinking, or alcohol use disorders. These conditions were selected because they are present in almost a third of patients seen in primary care settings. Innovations included assigning the care manager role to trained lay providers supported by computer-based tools; providing all care management centrally by phone - i.e., the intervention was delivered without any face-to-face contact between the patient and the care team; and basing patient eligibility and treatment selection on a transdiagnostic approach using the same eligibility criteria and the same treatment algorithms regardless of the participants' specific psychiatric diagnosis. This paper describes the design of this RCT and discusses the rationale for its main design features.

Increasing access to care using clinical pharmacy specialist providers in outpatient mental health: Successful practice integration within the Department of Veterans Affairs

BACKGROUND

To highlight the role and impact of the mental health (MH) clinical pharmacist provider in outpatient MH through successful practice integration into team-based care.

OBJECTIVE

The MH clinical pharmacy specialist (CPS) provider serves in many key roles to improve patient-centered care and medication outcomes by supporting the needs of the MH team, patients, and caregivers in areas of comprehensive medication management. MH CPS providers are integrated as MH providers in general and specialty MH clinics, behavioral health clinics embedded in primary care, residential rehabilitation facilities, specialty MH programs, and in inpatient MH units to improve access, quality, and safety.

PRACTICE DESCRIPTION

There is a shortage of psychiatrists across the United States, which affects the ability to provide MH care to patients.

PRACTICE INNOVATION

There is a need to transform the MH team to include clinicians focused on providing services to the growing population with MH conditions; hence, the expertise of the MH CPS is an asset to increase access to comprehensive medication management services.

EVALUATION

The MH CPS provider serves patients with a variety of MH conditions, managing medication-related adverse events, performing ongoing and acute medication monitoring, and collaborating with other health care providers for management of new diagnoses.

RESULTS

The MH CPS provider improves access to care, clinical outcomes, and safety when deployed as direct patient care providers on Veterans Affairs (VA) interprofessional care teams. VA MH clinical pharmacy practice continues to demonstrate what the MH CPS provider, practicing at the top of their license, can achieve as a core member in MH team-based care.

CONCLUSION

These foundational concepts can be applied to further expand MH clinical pharmacy practice into non-VA settings through the use collaborative practice agreements and integration into interprofessional care teams, providing access to patients in need of MH care.

Predictors of Treatment Referral after AUDIT-C Screening for Heavy Drinking

OBJECTIVES

The Veterans Health Administration has implemented annual screening for heavy drinking during primary care encounters using the 3-item Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire and made specialized services available to patients with alcohol use disorders (AUDs). We sought to identify the factors that influence whether a patient who has an elevated AUDIT-C score receives appropriate care in the context of an integrated mental health services program. We focused on higher AUDIT-C scores, as these are seen in individuals who are most likely to have a moderate-to-severe AUD and more severe alcohol-related consequences.

METHODS

Utilizing electronic health record data, we conducted a four-year retrospective study of veterans at high-risk for an AUD, based upon an AUDIT-C score >=8 recorded during a primary care encounter at a Veterans Affairs Medical Center and its community-based outpatient clinics.

RESULTS

In multivariate analysis, the predictors of treatment referral were younger age, being non-white, higher AUDIT-C score, and main campus location. Among patients referred for treatment, younger age and being white were associated with an increased likelihood of completing a pre-treatment assessment.

CONCLUSIONS

Efforts to increase the consistency of treatment referrals, according to established clinical guidelines, could enhance the effectiveness of AUDIT-C screening during primary care visits. Subgroups of patients who may benefit from such efforts include individuals with high-risk but sub-maximal AUDIT-C scores, older patients, and patients who are seen at community-based outpatient clinics.

Alcohol misuse in older people

The clinical and public mental health aspects of alcohol misuse in older people (both men and women) have increasing relevance for both old age and addiction psychiatrists. Clinical presentations are often complex and involve a number of different psychiatric, physical and psychosocial factors. The assessment, treatment and aftercare of alcohol-related and comorbid other mental disorders will also involve a broad range of interventions from a wide range of practitioners. Given its growing clinical relevance, there are particular areas, such as alcohol-related brain damage and drug interactions with alcohol, that deserve special attention.

Interventions to prevent and reduce excessive alcohol consumption in older people: a systematic review and meta-analysis

Background

harmful alcohol consumption is reported to be increasing in older people. To intervene and reduce associated risks, evidence currently available needs to be identified.

Methods

two systematic reviews in older populations (55+ years): (1) Interventions to prevent or reduce excessive alcohol consumption; (2) Interventions as (1) also reporting cognitive and dementia outcomes. Comprehensive database searches from 2000 to November 2016 for studies in English, from OECD countries. Alcohol dependence treatment excluded. Data were synthesised narratively and using meta-analysis. Risk of bias was assessed using NICE methodology. Reviews are reported according to PRISMA.

Results

thirteen studies were identified, but none with cognition or dementia outcomes. Three related to primary prevention; 10 targeted harmful or hazardous older drinkers. A complex range of interventions, intensity and delivery was found. There was an overall intervention effect for 3- and 6-month outcomes combined (8 studies; 3,591 participants; pooled standard mean difference (SMD) −0.18 (95% CI −0.28, −0.07) and 12 months (6 studies; 2,788 participants SMD −0.16 (95% CI −0.32, −0.01) but risk of bias for most studies was unclear with significant heterogeneity. Limited evidence (three studies) suggested more intensive interventions with personalised feedback, physician advice, educational materials, follow-up could be most effective. However, simple interventions including brief interventions, leaflets, alcohol assessments with advice to reduce drinking could also have a positive effect.

Conclusions

alcohol interventions in older people may be effective but studies were at unclear or high risk of bias. Evidence gaps include primary prevention, cost-effectiveness, impact on cognitive and dementia outcomes.

Alcohol and age

Alcohol consumption constitutes a substantial burden of disease. Older people are being admitted to hospital for alcohol problems in increasing numbers. A recent systematic review reports cautious supportive evidence for primary prevention interventions in reducing excessive alcohol consumption in older drinkers, but does not focus on treatment of dependent drinkers. The evidence base for treatment interventions for dependent drinkers is comparatively limited, but it is growing. In addition to brief interventions, specialist outpatient treatment and inpatient treatment have been evaluated.The responses of older people to treatment are promising: they want to abstain, they have the capacity to change, they respond well to brief advice and motivational enhancement therapy, they achieve improvements at least as comparable to younger counterparts-and sometimes better-and they do have the prospect of long-term recovery.There is a need to develop services tailored to the needs of older substance misusers. Education of the workforce, including medical students and other health care professionals, is the key. Collaboration and coordination of services, training, research and policy are essential.There are very few designated services for older substance misusers in the UK and only 7% of older people who need treatment for alcohol problems access them. There is a massive gap in the whole gamut of research from basic to clinical research in this vulnerable patient population: this has to be developed if management is to be effective and up to date.

Collaborative Care for Psychiatric Disorders in Older Adults: A Systematic Review

OBJECTIVE

To evaluate the mode of implementation, clinical outcomes, cost-effectiveness, and the factors influencing uptake and sustainability of collaborative care for psychiatric disorders in older adults.

DESIGN

Systematic review.

SETTING

Primary care, home health care, seniors' residence, medical inpatient and outpatient.

PARTICIPANTS

Studies with a mean sample age of 60 years and older.

INTERVENTION

Collaborative care for psychiatric disorders.

METHODS

PubMed, MEDLINE, Embase, and Cochrane databases were searched up until October 2016. Individual randomized controlled trials and cohort, case-control, and health service evaluation studies were selected, and relevant data were extracted for qualitative synthesis.

RESULTS

Of the 552 records identified, 53 records (from 29 studies) were included. Very few studies evaluated psychiatric disorders other than depression. The mode of implementation differed based on the setting, with beneficial use of telemedicine. Clinical outcomes for depression were significantly better compared with usual care across settings. In depression, there is some evidence for cost-effectiveness. There is limited evidence for improved dementia care and outcomes using collaborative care. There is a lack of evidence for benefit in disorders other than depression or in settings such as home health care and general acute inpatients. Attitudes and skill of primary care staff, availability of resources, and organizational support are some of the factors influencing uptake and implementation.

CONCLUSIONS

Collaborative care for depressive disorders is feasible and beneficial among older adults in diverse settings. There is a paucity of studies on collaborative care in conditions other than depression or in settings other than primary care, indicating the need for further evaluation.

Comparing behavioral health models for reducing risky drinking among older male veterans

BACKGROUND

Screening older veterans in Veterans Affairs Medical Center (VAMC) primary care clinics for risky drinking facilitates early identification and referral to treatment.

OBJECTIVE

This study compared two behavioral health models, integrated care (a standardized brief alcohol intervention co-located in primary care clinics) and enhanced referral care (referral to specialty mental health or substance abuse clinics), for reducing risky drinking among older male VAMC primary care patients. VAMC variation was also examined.

METHOD

A secondary analysis of longitudinal data from the Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) study, a multisite randomized controlled trial, was conducted with a sample of older male veterans (n = 438) who screened positive for risky drinking and were randomly assigned to integrated or enhanced referral care at five VAMCs.

RESULTS

Generalized estimating equations revealed no differences in either behavioral health model for reducing risky drinking at a 6-month follow-up (AOR: 1.46; 95% CI: 0.42-5.07). Older veterans seen at a VAMC providing geriatric primary care and geriatric evaluation and management teams had lower odds of risky drinking (AOR: 0.24; 95% CI: 0.07-0.81) than those seen at a VAMC without geriatric primary care services.

CONCLUSIONS

Both integrated and enhanced referral care reduced risky drinking among older male veterans. However, VAMCs providing integrated behavioral health and geriatric specialty care may be more effective in reducing risky drinking than those without these services. Integrating behavioral health into geriatric primary care may be an effective public health approach for reducing risky drinking among older veterans.

A Qualitative Study of Service Provision for Alcohol Related Health Issues in Mid to Later Life

Aims

Epidemiological surveys over the last 20 years show a steady increase in the amount of alcohol consumed by older age groups. Physiological changes and an increased likelihood of health problems and medication use make older people more likely than younger age groups to suffer negative consequences of alcohol consumption, often at lower levels. However, health services targeting excessive drinking tend to be aimed at younger age groups. The aim of this study was to gain an in-depth understanding of experiences of, and attitudes towards, support for alcohol related health issues in people aged 50 and over.

Methods

Qualitative interviews (n = 24, 12 male/12 female, ages 51–90 years) and focus groups (n = 27, 6 male/21 female, ages 50–95 years) were carried out with a purposive sample of participants who consumed alcohol or had been dependent.

Findings

Participants’ alcohol misuse was often covert, isolated and carefully regulated. Participants tended to look first to their General Practitioner for help with alcohol. Detoxification courses had been found effective for dependent participants but only in the short term; rehabilitation facilities were appreciated but seen as difficult to access. Activities, informal groups and drop-in centres were endorsed. It was seen as difficult to secure treatment for alcohol and mental health problems together. Barriers to seeking help included functioning at a high level, concern about losing positive aspects of drinking, perceived stigma, service orientation to younger people, and fatalistic attitudes to help-seeking. Facilitators included concern about risk of fatal illness or pressure from significant people.

Conclusion

Primary care professionals need training on improving the detection and treatment of alcohol problems among older people. There is also a compelling need to ensure that aftercare is in place to prevent relapse. Strong preferences were expressed for support to be provided by those who had experienced alcohol problems themselves.

Implementation of a Brief Treatment Counseling Toolkit in Federally Qualified Healthcare Centers: Patient and Clinician Utilization and Satisfaction

INTRODUCTION

The need to integrate behavioral health care within medical settings is widely recognized, and integrative care approaches are associated with improved outcomes for a range of disorders. As substance use treatment integration efforts expand within primary care settings, training behavioral health providers in evidence-based brief treatment models that are cost-effective and easily fit within the medical flow is essential.

METHODS

Guided by principles drawn from Diffusion of Innovations theory (Rogers, 2003) and the Consolidated Framework of Implementation Research (Damschroder et al., 2009), we adapted elements of Motivational Enhancement Therapy, cognitive-behavioral therapy, and 12-step facilitation into a brief counseling toolkit. The toolkit is a menu driven assortment of 35 separate structured clinical interventions that each include client takeaway resources to reinforce brief clinical contacts. We then implemented this toolkit in the context of a randomized clinical trial in three Federally Qualified Healthcare Centers. Behavioral Health Consultants (BHCs) used a pre-screening model wherein 10,935 patients received a brief initial screener, and 2011 received more in-depth substance use screening. Six hundred patients were assigned to either a single session brief intervention or an expanded brief treatment encompassing up to five additional sessions. We conducted structured interviews with patients, medical providers, and BHCs to obtain feedback on toolkit implementation.

RESULTS

On average, patients assigned to brief treatment attended 3.29 sessions. Fifty eight percent of patients reported using most or all of the educational materials provided to them. Patients assigned to brief treatment reported that the BHC sessions were somewhat more helpful than did patients assigned to a single session brief intervention (p=.072). BHCs generally reported that the addition of the toolkit was helpful to their work in delivering screening and brief treatment.

DISCUSSION

This work is significant because it provides support to clinicians in delivering evidence-based brief interventions and has been formatted into presentation styles that can be presented flexibly depending on patient need.

Implementation strategies to enhance management of heavy alcohol consumption in primary health care: a meta-analysis

BACKGROUND AND AIMS

Screening and brief interventions (SBI) delivered in primary health care (PHC) are cost-effective in decreasing alcohol consumption; however, they are underused. This study aims to identify implementation strategies that focus on SBI uptake and measure impact on: (1) heavy drinking and (2) delivery of SBI in PHC.

METHODS

Meta-analysis was conducted of controlled trials of SBI implementation strategies in PHC to reduce heavy drinking. Key outcomes included alcohol consumption, screening, brief interventions and costs in PHC. Predictor measures concerned single versus multiple strategies, type of strategy, duration and physician-only input versus that including mid-level professionals. Standardized mean differences (SMD) were calculated to indicate the impact of implementation strategies on key outcomes. Effect sizes were aggregated using meta-regression models.

RESULTS

The 29 included studies were of moderate methodological quality. Strategies had no overall impact on patients' reported alcohol consumption [SMD=0.07; 95% confidence interval (CI)=-0.02 to 0.16], despite improving screening (SMD=0.53; 95% CI=0.28-0.78) and brief intervention delivery (SMD=0.64;95% CI=0.27-1.02). Multi-faceted strategies, i.e. professional and/or organizational and/or patient-orientated strategies, seemed to have strongest effects on patients' alcohol consumption (P<0.05, compared with professional-orientated strategies alone). Regarding SBI delivery, combining professional with patient-orientated implementation strategies had the highest impact (P<0.05). Involving other staff besides physicians was beneficial for screening (P<0.05).

CONCLUSIONS

To increase delivery of alcohol screening and brief interventions and decrease patients' alcohol consumption, implementation strategies should include a combination of patient-, professional- and organizational-orientated approaches and involve mid-level health professionals as well as physicians.

Specialty substance use disorder services following brief alcohol intervention: a meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Brief alcohol interventions in medical settings are efficacious in improving self-reported alcohol consumption among those with low-severity alcohol problems. Screening, Brief Intervention and Referral to Treatment initiatives presume that brief interventions are efficacious in linking patients to higher levels of care, but pertinent evidence has not been evaluated. We estimated main and subgroup effects of brief alcohol interventions, regardless of their inclusion of a referral-specific component, in increasing the utilization of alcohol-related care.

METHODS

A systematic review of English language papers published in electronic databases to 2013. We included randomized controlled trials (RCTs) of brief alcohol interventions in general health-care settings with adult and adolescent samples. We excluded studies that lacked alcohol services utilization data. Extractions of study characteristics and outcomes were standardized and conducted independently. The primary outcome was post-treatment alcohol services utilization assessed by self-report or administrative data, which we compared across intervention and control groups.

RESULTS

Thirteen RCTs met inclusion criteria and nine were meta-analyzed (n = 993 and n = 937 intervention and control group participants, respectively). In our main analyses the pooled risk ratio (RR) was = 1.08, 95% confidence interval (CI) = 0.92-1.28. Five studies compared referral-specific interventions with a control condition without such interventions (pooled RR = 1.08, 95% CI = 0.81-1.43). Other subgroup analyses of studies with common characteristics (e.g. age, setting, severity, risk of bias) yielded non-statistically significant results.

CONCLUSIONS

There is a lack of evidence that brief alcohol interventions have any efficacy for increasing the receipt of alcohol-related services.

Older adults recently started on psychotropic medication: where are the symptoms?

OBJECTIVE

The objective of this study is to understand the characteristics of older adults on newly prescribed psychotropic medication with minimal psychiatric symptoms.

METHODS

Naturalistic cohort study of non-institutionalized older adults in Pennsylvania participating in the Pharmaceutical Assistance Contract for the Elderly. Persons newly prescribed antidepressant or anxiolytic monotherapy or combination therapy were contacted for clinical assessment by a telephone-based behavioral health service. The initial assessment included standardized mental health screening instruments and scales including the Blessed Orientation-Memory-Concentration test, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Medical Outcomes Survey (SF-12). In addition, patients were asked for their understanding of the prescription indication.

RESULTS

Of the 254 participants who met minimal symptom criteria (Patient Health Questionnaire-9 < 5 and Generalized Anxiety Disorder-7 < 5), women comprised slightly more of the anxiolytic compared with antidepressant monotherapy group (88.9% vs. 76.7%, p = 0.04). The most common self-reported reason for prescription of an antidepressant or anxiolytic was depression or anxiety, respectively, despite near-absence of these symptoms on clinical assessment. Comparing monotherapy to combination therapy groups, those with combination therapy were more likely to report a history of depression (12.6% vs. 1.8%, p < 0.001) and also report depression as the reason for the prescription (40.2% vs. 21.0%, p < 0.01).

CONCLUSIONS

In this sample of older adults on new psychotropic medication with minimal psychiatric symptoms, there are few patient characteristics that distinguish those on antidepressant versus anxiolytic monotherapy or those on monotherapy versus combination therapy. While quality of care in late-life mental health has focused on improving detection and treatment, there should be further attention to low-symptom patients potentially receiving inappropriate pharmacotherapy.

Chronic care management for substance dependence in primary care among patients with co-occurring disorders

OBJECTIVE

Co-occurring mental and substance use disorders are associated with worse outcomes than a single disorder alone. In this exploratory subgroup analysis of a randomized trial, the authors hypothesized that providing chronic care management (CCM) for substance dependence in a primary care setting would have a beneficial effect among persons with substance dependence and major depressive disorder or posttraumatic stress disorder (PTSD).

METHODS

Adults (N=563) with alcohol dependence, drug dependence, or both were assigned to CCM or usual primary care. CCM was provided by a nurse care manager, social worker, internist, and psychiatrist. Clinical outcomes (any use of opioids or stimulants or heavy drinking and severity of depressive and anxiety symptoms) and treatment utilization (emergency department use and hospitalization) were measured at three, six, and 12 months after enrollment. Longitudinal regression models were used to compare randomized arms within the subgroups of participants with major depressive disorder or PTSD.

RESULTS

Among all participants, 79% met criteria for major depressive disorder and 36% met criteria for PTSD at baseline. No significant effect of CCM was observed within either subgroup for any outcome, including any use of opioids or stimulants or heavy drinking, depressive symptoms, anxiety symptoms, and any hospitalizations or number of nights hospitalized. Among participants with depression, those receiving CCM had fewer days in the emergency department compared with the control group, but the finding was of only borderline significance (p=.06).

CONCLUSIONS

Among patients with co-occurring substance dependence and mental disorders, CCM was not significantly more effective than usual care for improving clinical outcomes or treatment utilization.

Substance abuse among older adults

Although the myth that older adults do not use mood-altering substances persists, evidence suggests that substance use among older adults has been underidentified for decades. The baby boom generation is unique in its exposure to, attitudes toward, and prevalence of substance use-causing projected rates of substance use to increase over the next twenty years. Given their unique biological vulnerabilities and life stage, older adults who misuse substances require special attention. Prevalence rates of substance use and misuse among older adults, methods of screening and assessment unique to older adults, and treatment options for older adults are reviewed.

Chronic care management for dependence on alcohol and other drugs: the AHEAD randomized trial

IMPORTANCE

People with substance dependence have health consequences, high health care utilization, and frequent comorbidity but often receive poor-quality care. Chronic care management (CCM) has been proposed as an approach to improve care and outcomes.

OBJECTIVE

To determine whether CCM for alcohol and other drug dependence improves substance use outcomes compared with usual primary care.

DESIGN, SETTING, AND PARTICIPANTS

The AHEAD study, a randomized trial conducted among 563 people with alcohol and other drug dependence at a Boston, Massachusetts, hospital-based primary care practice. Participants were recruited from September 2006 to September 2008 from a freestanding residential detoxification unit and referrals from an urban teaching hospital and advertisements; 95% completed 12-month follow-up.

INTERVENTIONS

Participants were randomized to receive CCM (n=282) or no CCM (n=281). Chronic care management included longitudinal care coordinated with a primary care clinician; motivational enhancement therapy; relapse prevention counseling; and on-site medical, addiction, and psychiatric treatment, social work assistance, and referrals (including mutual help). The no CCM (control) group received a primary care appointment and a list of treatment resources including a telephone number to arrange counseling.

MAIN OUTCOMES AND MEASURES

The primary outcome was self-reported abstinence from opioids, stimulants, or heavy drinking. Biomarkers were secondary outcomes.

RESULTS

There was no significant difference in abstinence from opioids, stimulants, or heavy drinking between the CCM (44%) and control (42%) groups (adjusted odds ratio, 0.84; 95% CI, 0.65-1.10; P=.21). No significant differences were found for secondary outcomes of addiction severity, health-related quality of life, or drug problems. No subgroup effects were found except among those with alcohol dependence, in whom CCM was associated with fewer alcohol problems (mean score, 10 vs 13; incidence rate ratio, 0.85; 95% CI, 0.72-1.00; P=.048).

CONCLUSIONS AND RELEVANCE

Among persons with alcohol and other drug dependence, CCM compared with a primary care appointment but no CCM did not increase self-reported abstinence over 12 months. Whether more intensive or longer-duration CCM is effective requires further investigation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00278447.

A review of existing treatments for substance abuse among the elderly and recommendations for future directions

Background

With population aging, there is widespread recognition that the healthcare system must be prepared to serve the unique needs of substance using older adults (OA) in the decades ahead. As such, there is an increasingly urgent need to identify efficient and effective substance abuse treatments (SAT) for OA. Despite this need, there remains a surprising dearth of research on treatment for OA.

Aims of review

This review describes and evaluates studies on SAT applied to and specifically designed for OA over the last 30 years with an emphasis on methodologies used and the knowledge gained.

Methods

Using three research databases, 25 studies published in the last 30 years which investigated the impact of SAT on OA and met specific selection criteria were reviewed.

Results

A majority of the studies were methodologically limited in that they were pre-to-post or post-test only studies. Of the randomized controlled trials, many were limited by sample sizes of 15 individuals or less per group, making main effects difficult to detect. Thus, with caution, the literature suggests that among treatment seeking OA, treatment, whether age-specific or mixed-age, generally works yielding rates of abstinence comparable to general populations and younger cohorts. It also appears that with greater treatment exposure (higher dosage), regardless of level of care, OA do better. Finally, based on only two studies, age-specific treatment appears to potentiate treatment effects for OA. Like younger adults, OA appear to have a heterogeneous response to treatments, and preliminary evidence suggests a possibility of treatment matching for OA.

Conclusions

Expansion of research on SAT for OA is urgently needed for maximum effectiveness and efficiency of the healthcare system serving these individuals. Future research needs to include laboratory and community based randomized controlled trials with high internal validity of previously vetted evidenced-based practices, including Motivational Interviewing, cognitive behavioral therapy, and medications such as naltrexone, to determine the best fit for OA.

Testing the effects of brief intervention in primary care for problem drug use in a randomized controlled trial: rationale, design, and methods

BACKGROUND

A substantial body of research has established the effectiveness of brief interventions for problem alcohol use. Following these studies, national dissemination projects of screening, brief intervention (BI), and referral to treatment (SBIRT) for alcohol and drugs have been implemented on a widespread scale in multiple states despite little existing evidence for the impact of BI on drug use for non-treatment seekers. This article describes the design of a study testing the impact of SBIRT on individuals with drug problems, its contributions to the existing literature, and its potential to inform drug policy.

METHODS/DESIGN

The study is a randomized controlled trial of an SBIRT intervention carried out in a primary care setting within a safety net system of care. Approximately 1,000 individuals presenting for scheduled medical care at one of seven designated primary care clinics who endorse problematic drug use when screened are randomized in a 1:1 ratio to BI versus enhanced care as usual (ECAU). Individuals in both groups are reassessed at 3, 6, 9, and 12 months after baseline. Self-reported drug use and other psychosocial measures collected at each data point are supplemented by urine analysis and public health-related data from administrative databases.

DISCUSSION

This study will contribute to the existing literature by providing evidence for the impact of BI on problem drug use based on a broad range of measures including self-reported drug use, urine analysis, admission to drug abuse treatment, and changes in utilization and costs of health care services, arrests, and death with the intent of informing policy and program planning for problem drug use at the local, state, and national levels.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00877331.

The growing problem of illicit substance abuse in the elderly: a review

OBJECTIVE

To explore and integrate the extant data on the subject of illicit substance use and abuse in the elderly and to determine shortcomings in the current understanding of the problem and potential topics of future research.

DATA SOURCES

Ovid MEDLINE was searched (1960-2011) using the keywords substance use disorders and geriatrics; PsycINFO was searched (1967-2011) using the keywords drug abuse and geriatrics.

DATA EXTRACTION

The searches of Ovid MEDLINE and PsycINFO returned 35 and 85 results, respectively. Other relevant articles were identified by checking reference lists of the identified studies. A total of 26 articles with a focus on use of illicit substances, excluding alcohol, over-the-counter drugs, and prescription drugs, in the elderly were determined to be applicable to the review.

DATA SYNTHESIS

Limited data were available to combine between studies, but certain conclusions could be generalized among separate sources.

RESULTS

Geriatric substance abuse is a topic of growing interest, importance, and research; however, most of the existing literature has focused on licit substances. Illicit substance abuse has been incorrectly assumed to end as patients age, whereas in reality, elderly drug users are increasingly common and have a unique profile quite different from that of their younger counterparts.

CONCLUSIONS

Geriatric substance abuse is a common problem and includes both licit and illicit substances. There are not yet reliable screening instruments or treatment methods for identification and treatment of illicit substance abuse in the elderly. A high index of suspicion and consideration of illicit substance use as a real possibility are vital for early recognition and diagnosis of such abuse in the elderly.

Integration of priority population, health and nutrition interventions into health systems: systematic review

BACKGROUND

Objective of the study was to assess the effects of strategies to integrate targeted priority population, health and nutrition interventions into health systems on patient health outcomes and health system effectiveness and thus to compare integrated and non-integrated health programmes.

METHODS

Systematic review using Cochrane methodology of analysing randomised trials, controlled before-and-after and interrupted time series studies. We defined specific strategies to search PubMed, CENTRAL and the Cochrane Effective Practice and Organisation of Care Group register, considered studies published from January 1998 until September 2008, and tracked references and citations. Two reviewers independently agreed on eligibility, with an additional arbiter as needed, and extracted information on outcomes: primary (improved health, financial protection, and user satisfaction) and secondary (improved population coverage, access to health services, efficiency, and quality) using standardised, pre-piloted forms. Two reviewers in the final stage of selection jointly assessed quality of all selected studies using the GRADE criteria.

RESULTS

Of 8,274 citations identified 12 studies met inclusion criteria. Four studies compared the benefits of Integrated Management of Childhood Illnesses in Tanzania and Bangladesh, showing improved care management and higher utilisation of health facilities at no additional cost. Eight studies focused on integrated delivery of mental health and substance abuse services in the United Kingdom and United States of America. Integrated service delivery resulted in better clinical outcomes and greater reduction of substance abuse in specific sub-groups of patients, with no significant difference found overall. Quality of care, patient satisfaction, and treatment engagement were higher in integrated delivery models.

CONCLUSIONS

Targeted priority population health interventions we identified led to improved health outcomes, quality of care, patient satisfaction and access to care. Limited evidence with inconsistent findings across varied interventions in different settings means no general conclusions can be drawn on the benefits or disadvantages of integrated service delivery.

Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking

ISSUES

Although screening and brief intervention (BI) in the primary-care setting reduces unhealthy alcohol use, its efficacy among patients with dependence has not been established. This systematic review sought to determine whether evidence exists for BI efficacy among patients with alcohol dependence identified by screening in primary-care settings.

APPROACH

We included randomised controlled trials (RCTs) extracted from eight systematic reviews and electronic database searches published through September 2009. These RCTs compared outcomes among adults with unhealthy alcohol use identified by screening who received BI in a primary-care setting with those who received no intervention.

KEY FINDINGS

Sixteen RCTs, including 6839 patients, met the inclusion criteria. Of these, 14 excluded some or all persons with very heavy alcohol use or dependence; one in which 35% of 175 patients had dependence found no difference in an alcohol severity score between groups; and one in which 58% of 24 female patients had dependence showed no efficacy.

CONCLUSION AND IMPLICATIONS

Alcohol screening and BI has efficacy in primary care for patients with unhealthy alcohol use, but there is no evidence for efficacy among those with very heavy use or dependence. As alcohol screening identifies both dependent and non-dependent unhealthy use, the absence of evidence for the efficacy of BI among primary-care patients with screening-identified alcohol dependence raises questions regarding the efficiency of screening and BI, particularly in settings where dependence is common. The finding also highlights the need to develop new approaches to help such patients, particularly if screening and BI are to be disseminated widely.[Saitz R. Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking.

Effectiveness of service linkages in primary mental health care: a narrative review part 1

BACKGROUND

With the move to community care and increased involvement of generalist health care providers in mental health, the need for health service partnerships has been emphasised in mental health policy. Within existing health system structures the active strategies that facilitate effective partnership linkages are not clear. The objective of this study was to examine the evidence from peer reviewed literature regarding the effectiveness of service linkages in primary mental health care.

METHODS

A narrative and thematic review of English language papers published between 1998 and 2009. Studies of analytic, descriptive and qualitative designs from Australia, New Zealand, UK, Europe, USA and Canada were included. Data were extracted to examine what service linkages have been used in studies of collaboration in primary mental health care. Findings from the randomised trials were tabulated to show the proportion that demonstrated clinical, service delivery and economic benefits.

RESULTS

A review of 119 studies found ten linkage types. Most studies used a combination of linkage types and so the 42 RCTs were grouped into four broad linkage categories for meaningful descriptive analysis of outcomes. Studies that used multiple linkage strategies from the suite of "direct collaborative activities" plus "agreed guidelines" plus "communication systems" showed positive clinical (81%), service (78%) and economic (75%) outcomes. Most evidence of effectiveness came from studies of depression. Long term benefits were attributed to medication concordance and the use of case managers with a professional background who received expert supervision. There were fewer randomised trials related to collaborative care of people with psychosis and there were almost none related to collaboration with the wider human service sectors. Because of the variability of study types we did not exclude on quality or attempt to weight findings according to power or effect size.

CONCLUSION

There is strong evidence to support collaborative primary mental health care for people with depression when linkages involve "direct collaborative activity", plus "agreed guidelines" and "communication systems".

Primary care-based intervention to reduce at-risk drinking in older adults: a randomized controlled trial

AIMS

To examine whether a multi-faceted intervention among older at-risk drinking primary care patients reduced at-risk drinking and alcohol consumption at 3 and 12 months.

DESIGN

Randomized controlled trial.

SETTING

Three primary care sites in southern California.

PARTICIPANTS

Six hundred and thirty-one adults aged ≥ 55 years who were at-risk drinkers identified by the Comorbidity Alcohol Risk Evaluation Tool (CARET) were assigned randomly between October 2004 and April 2007 during an office visit to receive a booklet on healthy behaviors or an intervention including a personalized report, booklet on alcohol and aging, drinking diary, advice from the primary care provider and telephone counseling from a health educator at 2, 4 and 8 weeks.

MEASUREMENTS

The primary outcome was the proportion of participants meeting at-risk criteria, and secondary outcomes were number of drinks in past 7 days, heavy drinking (four or more drinks in a day) in the past 7 days and risk score.

FINDINGS

At 3 months, relative to controls, fewer intervention group participants were at-risk drinkers [odds ratio (OR) 0.41; 95% confidence interval (CI) 0.22-0.75]; they reported drinking fewer drinks in the past 7 days [rate ratio (RR) 0.79; 95% CI 0.70-0.90], less heavy drinking (OR 0.46; 95% CI 0.22-0.99) and had lower risk scores (RR 0.77 95% CI 0.63-0.94). At 12 months, only the difference in number of drinks remained statistically significant (RR 0.87; 95% CI 0.76-0.99).

CONCLUSIONS

A multi-faceted intervention among older at-risk drinkers in primary care does not reduce the proportions of at-risk or heavy drinkers, but does reduce amount of drinking at 12 months.

Suicide risk and prevention in veteran populations

Rates of suicide among veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) rose significantly from 2005 to 2007, adding to existing concerns about veteran suicide risk by the Department of Veterans Affairs. This paper summarizes the available data about risk and rates of suicide in veterans, including the choice of appropriate comparison groups and the identification of risk factors. The data suggest that taking into account the selection bias of who enters the military (known as the healthy soldier effect), rates of suicide in veterans are higher than expected, especially among activity duty OEF/OIF veterans and even more so among those who experienced injuries and trauma. Thus, the experiences of war and the downstream sequelae, in particular the individuals' psychological reactions and societal responses, lead to suicide risk. This paper describes the VA's response to these data in developing and implementing suicide prevention interventions.

Determinants of early reductions in drinking in older at-risk drinkers participating in the intervention arm of a trial to reduce at-risk drinking in primary care

OBJECTIVES

To describe differences between older at-risk drinkers, as determined using the Comorbidity Alcohol Risk Evaluation Tool, who reduced drinking and those who did not after an initial intervention and to determine factors associated with early reductions in drinking.

DESIGN

Secondary analyses of data from a randomized controlled trial.

SETTING

Seven primary care sites.

PARTICIPANTS

Subjects randomized to the intervention group who completed the first health educator call approximately 2 weeks after enrollment (n=239).

INTERVENTION

Personalized risk reports, booklets on alcohol-associated risks, and advice from physicians, followed by a health educator call.

MEASURMENTS

Reductions in number of alcoholic drinks.

RESULTS

Thirty-nine percent of the sample had reduced drinking within 2 weeks of receiving the initial intervention. According to the final multiple logistic regression model, those who were concerned about alcohol-related risks (odds ratio (OR)=2.03, 95% confidence interval (CI)=1.01-4.07), read through the educational booklet (OR=2.97, 95% CI=1.48-5.95), or perceived that their physicians discussed risks and advised changing drinking behaviors (OR=4.1, 95% CI=2.02-8.32) had greater odds of reducing drinking by the first health educator call.

CONCLUSION

Concern about risks, reading educational material, and perception of physicians providing advice to reduce drinking were associated with early reductions in alcohol use in older at-risk drinkers. Understanding these factors will enable development of better intervention strategies to reduce unhealthy alcohol use.

Gaps in addressing problem drinking: overcoming primary care and alcohol treatment deficiencies

Despite the high prevalence of problem drinking among Americans, primary care physicians often fail to address this major health threat. In addition, once alcohol use disorders are identified, patients often fail to receive coordinated medical and substance abuse treatment. This article reviews four types of barriers as well as potential facilitators to improving the prevention and management of problem drinking. First, primary care physicians are poorly trained about the clinical relevance of addressing alcohol problems in their daily patient care. Second, primary care physicians are concerned about the stigma and health insurance problems encountered by patients diagnosed with alcohol use disorders. Third, primary care practices have limited organizational and financial support to identify and address alcohol problems. Fourth, primary care and alcohol treatment settings communicate and collaborate poorly in delivering patient care. Opportunities to overcome these challenges are discussed and must be initiated to reduce the myriad of adverse outcomes resulting from problem drinking.

Integrated specialty mental health care among older minorities improves access but not outcomes: results of the PRISMe study

OBJECTIVE

In this secondary data analysis of Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRIMSe) study, we hypothesized that older minorities who receive mental health services integrated in primary care settings would have greater service use and better mental health outcomes than older minorities referred to community services.

METHOD

We identified 2,022 (48% minorities) primary care patients 65 years and older, who met study inclusion criteria and had either alcohol misuse, depression, and/or anxiety. They were randomized to receive treatment for these disorders in the primary care clinic or to a brokerage case management model that linked patients to community-based services. Service use and clinical outcomes were collected at baseline, three months and six months post randomization on all participants.

RESULTS

Access to and participation in mental health /substance abuse services was greater in the integrated model than in referral; there were no treatment by ethnicity effects. There were no treatment effects for any of the clinical outcomes; Whites and older minorities in both integrated and referral groups failed to show clinically significant improvement in symptoms and physical functioning at 6 months.

CONCLUSIONS

While providing services in primary care results in better access to and use of these services, accessing these services is not enough for assuring adequate clinical outcomes.

Screening instruments for older adult depressive disorders: updating the evidence-based toolbox

The prevalence of clinically significant depressive disorders in persons 65 years of age or older in the United States has been estimated to be approximately 15%, increasing the risk for functional decline, morbidity, and mortality. Utilization of a well-chosen screening instrument has been shown to improve the rates of recognition of depressive disorders in older adults. This paper presents a targeted review of the most commonly accepted tools for case-finding of depressive disorders in older adults. After a review of the benefits and shortcomings of screening tools, the strengths, weaknesses, and utility of selected depression scales in geriatric clinical settings are discussed.

The Influence of Integration on the Expenditures and Costs of Mental Health and Substance Use Care: Results from the randomized PRISM-E Study

We compared the healthcare costs associated with an integrated care model to an enhanced referral model for the treatment of depression, anxiety, and at-risk drinking from the randomized Primary Care Research in Substance Abuse and Mental Health for the Elderly study. We examined total healthcare costs and cost components, separately for Veteran's Affairs and non-VA participants. No differences in total health expenditures were detected between study arms. No differences in behavioral health expenditures were detected for non-VA sites, but the VA integrated arm had slightly higher ($38; p<0.05) behavioral health costs. Differences in other types of services use were detected.

Expenditures in mental illness and substance use disorders among veteran clinic users with diabetes

Few studies have looked at the health-care expenditures of diabetes patients based on the type of co-occurring conditions of mental illness (MI) or substance use disorders (SUD). Our study analyzes the health-care expenditures associated with various diagnostic clusters of co-occurring drug, alcohol, tobacco use, and mental illness in veterans with diabetes. We merged Veteran Health Administration and Medicare fee-for-service claims database (fiscal years 1999 and 2000) for analysis (N = 390,253) using generalized linear models; SUD/MI were identified using International Classification of Diseases, 9th edition codes. The total average expenditures (fiscal year 2000) were lowest ($6,185) in the "No MI and No SUD" and highest ($19,801) for individuals with schizophrenia/other psychoses and alcohol/drug use. High expenditures were associated with both SUD and MI conditions in diabetes patients, and veterans with alcohol/drug use had the highest expenditures across all groups of MI. These findings reinforce the need to target groups with multiple comorbidities specifically those with serious mental illnesses and alcohol/drug use for interventions to reduce health-care expenditures.

Stemming the Tide of Suicide in Older White Men: A Call to Action

Preventing suicide has been identified as a national priority by recent commissions in the United States. Despite increased awareness of suicide as a public health problem, suicide in older adults remains a neglected topic in prevention strategies and research. This is especially true regarding elderly White men, who in terms of suicide rates have represented the most at-risk age group for the past half century. In light of the unprecedented aging of the United States as the baby boom generation enters late adulthood, suicide prevention initiatives that focus on aging males are needed to prevent a national crisis in geriatric mental health. This article provides a brief review of the perennially under-recognized reality of suicide in older men and prevention strategies that, if implemented, might help stem this rising tide of suicide in this vulnerable population.

Late-life depression and alcoholism

The relationship between alcohol use and later-life depression is complex. At-risk and problem drinking elevates the risk of depressive symptoms. The co-occurrence of alcohol use disorders and depression increases the potential for poor mental and physical health outcomes in older adults. Many older adults who are experiencing problems related to alcohol use do not meet alcohol abuse/dependence criteria. Depressive symptoms among older adults often are overlooked or misdiagnosed. The role of at-risk and problem alcohol use in depressive symptoms and vice versa may be underestimated. After a review of the literature, clinical recommendations for addressing late-life alcohol misuse and depression are presented.

Predictors of adherence within an intervention research study of the at-risk older drinker: PRISM-E

The aim of this study was to determine predictors of research adherence and treatment initiation in at-risk older drinkers. This investigation was conducted at primary care clinics in the Philadelphia Veteran Affairs Medical Center and the University of Pennsylvania, participating sites in a larger multisite study trial (PRISM-E). Persons aged 65 and older with appointments at participating clinics were eligible for recruitment (n = 8367). Approximately half (n = 4000) consented to the study, of which 145 were identified as at-risk drinkers and 125 agreed to treatment. Slightly more than half of the patients who agreed to treatment attended a mental health visit. The results suggest that predictors of research adherence and treatment initiation vary across research stage. Principal predictors include age, mental health status, and at-risk drinking attributes. Moreover, there was evidence that an integrated care treatment model may be capable of improving treatment initiation in at-risk older drinkers who have no history of substance management behaviors. Future researchers can use the current findings to create mechanisms to improve research participation and treatment initiation and target participants with classifications of poor adherence.